A clinician explains how to manage opioid overdoses by prioritizing airway and breathing before using naloxone, which should be titrated to stop assisted ventilation, not to wake patients. Newer street opioids like fentanyl analogs need higher doses, and too much naloxone risks acute withdrawal and pulmonary edema. A new needleless intranasal 4 mg device is now recommended.
Questions this video answers
4 milligrams in 0.1 mL (single small spray) per device.
2 mg in 2 mL (larger volume that often drips out of the nose).
About 0.5 milligrams historically used for heroin ("half a milligram").
Up to 10 milligrams may be needed to reverse some newer street opioids.
He states that 70% of people addicted to heroin and similar opiates are hepatitis C positive.
Chapters
Alright, I want to talk about our narcotic overdoses and the use of Narcan. The street drugs out there have changed over time. When it used to be heroin and fentanyl, then carfentanil and there's even this stuff called W18 out there. And all those different drugs have different resistances to Narcan, which is why in the past with just good old heroin, we used to get away with half a milligram of Narcan. And now you may have to give up to 10 milligrams of Narcan to reverse some of this stuff. Well, let's go over what we're really trying to do here, because I want to make sure that everybody's clear on what our goal is when it comes to these overdoses. First is we're trying to keep these people breathing and, well, oxygenated. So when you come across a narcotic overdose who is hypoxic and hypoventilatory, the first step should be to manage the airway. So open the airway, use bag valve mask and bag them up to get a good O2 Sat. Because once you've done that, the emergency is over, you've already fixed the problem. Now, the purpose of the Narcan is to keep us from having to intubate them, because if we have to intubate them, then the patient will end up being in the intensive care care unit, a much more prolonged stay and higher morbidity rate. But if you give too much Narcan to people who are addicted to opiates, you can put them into acute sudden withdrawal. This is not a good thing. So if you've had patients who've been vomiting after you gave them a lot of Narcan, you've put them into acute sudden withdrawal. Some of those patients will develop non cardiogenic pulmonary edema. Some of those actually can die from that condition. So our goal is to, is not to wake them up. So let me say that again, we are not trying to wake these people up. We are just trying to give them just enough Narcan so that we can deliver a sleeping, well oxygenated patient to the emergency department, preferably breathing on their own. So we're trying to give them just enough so that we don't have to keep bagging them anymore. So our first step is we're going to take over the airway and bag them and then we're going to, over a little more reasonable amount of time, slowly titrate up to get them under control so we can stop the bagging. We're going to be having a new Narcan device out there, and it's an intranasal Narcan, and It comes with 4 milligrams in a little tiny. Mr. And it's really designed looks a little like an Afrin nasal spray instead of what we're currently right now we're doing 2mg and 2cc's. It's a ton of volume. And you all know what happens. You put up the nose and sort of drips down their face. It's too much volume for the nose to handle. But now we're going to have a new device where it's really just a little tiny puff, is 0.1 ML. But it's only going to work if you clear out the nose. A lot of these overdoses we get there, and there's a lot of mucus in the nose. The drug's not going to work if you don't use a little suction device and clear out their nose. So when you get this out on the street, you'll see it's very simple to use. And it is the route of choice that I want you to use for our narcotic overdoses. The reason being is I want to try to avoid sharps on these folks. The statistics show that 70% of the folks that are addicted to heroin and similar opiates are already hepatitis C positive. So this is a very high risk for bloodborne pathogen exposure for our folks. So I'd rather use a needleless approach if we can, which is what this intranasal Narcan is all about. Now, again, if you've already bagged them and just by bagging them, they're breathing on their own, you might not need any Narcan at all. So let's not try to wake these folks up. Let's try to deliver some sleeping patients that are breathing well and oxygenating well to the emergency department. Now, I'm going to switch gears a little bit. It's still going to be on Narcan. But let's talk about cardiac arrest. Once you have decided to take over a patient's airway, either because you've decided you're going to put a supraglottic airway in or you're going to intubate them, there's no longer really any role for Narcan because the only purpose of Narcan is to prevent you from having to intubate them or put a supraglottic airway in. So if you have an overdose patient who's gone into cardiac arrest, there's really not really much point, logically speaking, to give them Narcan, because you've already determined this is a secondary cardiac arrest from hypoxia, and you should be breathing for these folks with a supraglottic airway right from the beginning, or a bag valve mass just before you put the supraglottic in. Once you're at that step, there's no point to give Narcan, period. So if you have a cardiac arrest from an overdose, there's definitely no role to give 10 milligrams of Narcan to those folks. If you really feel the need to give Narcan, you can stop at 2 milligrams. Or I would say you don't even need to give Narcan at all in that scenario.
